Priorities
6.1 We emphasised in Chapter 2 that the demand for health care is always likely to outstrip supply and that the capacity of health services to absorb resources is almost unlimited. Choices have therefore to be made about the use of available funds and priorities have to be set. The more pressure there is on resources, the more important it is to get the priorities clear; and the more difficult the choices are, the more important it is, in our view, that the ways in which they are reached are generally known and susceptible to public influence. In this chapter we consider how priorities are set in the NHS, and go on to discuss some of the current preferences.
6.2 The DHSS Consultative Document on priorities for health and personal social services in England begins by saying:
“This Consultative Document is a new departure. It is the first time an attempt has been made to establish rational and systematic priorities throughout the health and personal social services.”
The Hospital Plans of 1962 were an attempt to control services in accordance with a national strategy but they concentrated almost entirely on capital expenditure. In the late 1960s a series of reports drew attention to the neglect of long stay hospital services. White Papers about services for the mentally handicapped and the mentally ill in the early 1970s set out strategies for the development of health and personal social services for these groups. They paved the way for the comprehensive approach in the priorities document which each health department has published since NHS reorganisation. These differ slightly in detail but the broad emphasis in each is the same.
Setting priorities
6.3 Unfortunately there is no universally acceptable method of apportioning the limited health resources available to the NHS between different possible users and services. One might hope to be able to proceed on the basis of statistical, epidemiological and economic data, and quantified measures of need. Attempts have been made to measure “need”, for example by employing indices of mortality and morbidity or use of health service resources. The development of such indices may help to clarify possible ways of using scarce resources, but is unlikely to lead to any agreed formula for allocating resources to different services. Cost effectiveness studies, of which there are few, may assist the choice between different ways of delivering particular services, but they help little when the choice is between services delivering different kinds of care. Attempts to quantify gains in cost effectiveness terms are likely to be of only limited assistance because so many of the data are uncertain or fragmentary. But it is nevertheless important to use what tools are available in reaching national decisions.
6.4 The absence of objective criteria for settling health priorities means that decisions are for the most part a matter of judgment. NHS funds are provided annually by Parliament following consideration of the public expenditure White Paper which sets out the government’s views on the competing claims of different public expenditure programmes. Ministers and MPs are vulnerable to lobbying from various quarters and may consider that, for example, education services should be improved while health services are held They may be subject to the influences of the many national pressure groups and to pressures from their own constituents for a new hospital or health centre. The health professions in general, and doctors in particular, play a full part in this process. Ultimately it is Parliament that decides, but health ministers – and especially the Secretary of State for Social Services – probably have more influence than any other individuals on determining priorities in the NHS. A Secretary of State is subject to pressure groups, but is in a position to rule between them. His own preferences and judgment will therefore be important.
6.5 Health ministers are advised by their professional and administrative staff, and have access to professional advice from outside the health depart Some of this advice will come from epidemiologists, medical statisticians and community physicians, and will reflect their concern for the needs of populations and communities rather than individual patients. This may be resented by clinicians who have had to deal with the daily pressures of caring for individual patients and who may have very different views on needs and priorities. Those who have to take a wider view will seem to be less sensitive to individual need; while those concerned with patients must concentrate on their individual requirements. The tensions will be particularly marked where a reduction in resources for a group of patients is proposed.
6.6 In deciding priorities, ministers must also consider the influence that health services have on other services and vice-versa. Some services provided by local authorities are necessary to the NHS, and the availability of, for example, social services and suitable housing may be the determining factor. The personal social services are particularly important when arrangements are being made to transfer patients from hospital to their own homes or elsewhere in the community, or for helping them to remain in the community and be treated at home.
6.7 We have some comments on the way NHS priorities are determined. First, we believe it is important that the lay public should be involved in the process. The discussion should not be left solely to health professionals and administrators, though we recognise that policies and priorities must be realistic and reflect what can be achieved, and must therefore take account of the views of professional and management staff in the NHS on their feasibility and likely consequences. The media have an important role here: without informed discussion in newspapers, radio and television there is a risk that decisions at national level will not be exposed to public debate at all. We welcome the way in which, since reorganisation, the health departments have encouraged public discussion of priorities in the NHS, and believe that this approach should be developed. We recommend that more of the professional advice on which policies and priorities are based should be made public. This would strengthen the authority of the advice issued and lead to its readier acceptance in the field as well as promoting public discussion.
6.8 Second, much of the criticism of centrally determined priorities has been directed at the lack of clear guidance on the resource consequences of priorities. Guidance on priorities must take resource considerations into account. As the Rt Hon Dr David Owen MP, a former Minister of State at the DHSS, put it:
“We must be prepared to say, if we want priority for one sector, where the money should come from.”
This is particularly important when resources are tight and it is not possible to fund improvements in priority services from a general increase in allocations. Unfortunately Dr Owen’s wise advice has not always been followed.
6.9 Third, a frequent criticism of the way in which priorities are determined is that too many decisions are taken at national level and that there is insufficient local influence. There are arguments both ways here. Some factors can be effectively considered only at national level. It is an important function of the health departments to both influence and take into account developments and policies in government departments and other agencies outside the NHS which may affect health. A report by the Central Policy Review Staff pointed out that central government is “plural” and “joint behaviour is the exception rather than the rule”. It recommended that further steps should be taken inside central government “to reduce inter-service boundaries in the area of social policies.” We agree with this approach. Government, and in particular ministers, are also sensitive to public opinion and national political pressures in a way in which health authorities are not. Some pressure groups, including those representing important patient groups, operate effectively only at a national level. A more local determination of priorities might not be in the interests of these groups. Finally, the initiative in launching major policies in areas such as prevention can come only from central government.
6.10 Nevertheless, there are considerable advantages in encouraging local participation in setting priorities. Central government cannot know local requirements in any detail; and for historical and other reasons needs and the current levels of provision vary considerably from place to place. The two main advantages of allowing decisions on priorities to be taken locally are that it encourages a greater pride in the local service and sense of commitment to it, and stimulates experiment in methods of provision. The health departments have no monopoly of wisdom, nor are we dealing with a field which presents itself in terms of simple, logical answers to logically stated problems. While there are some aspects of policy making which can sensibly be undertaken only by the health departments, and the broad framework of priorities should be centrally determined at the level where political accountability lies, there is considerable scope for leaving more detailed discussion and decision on priorities to local level. With the increased public participation at the operational level of the NHS which we recommend in Chapter 20 the case for allowing priorities to be determined at that level will be strengthened.
Implementing priorities Difficulties
6.11 It may take a long time to achieve changes in the pattern of expenditure on different priority groups in the NHS. There are several reasons for this, but the most important is that the vast bulk of the funds available to the NHS are committed to services already in existence even before Parliament has voted them. Moreover, in practice:
“for hospital and community health services current expenditure needs to grow at about 1 per cent a year merely to allow for demographic change and to make some provision for the spread of improved medical techniques without detriment to standards in other parts of the service.”
When resources available to the NHS are rising slowly a government is probably doing well if it can divert as much as one per cent of NHS funds in any one year to the development of priority services.
6.12 In the implementation of priorities some patient groups and their services are going to gain, and others to lose. The lower the expansion rate of the service as a whole, the more acute the problem. Major breakthroughs in the cure of disease are rare; and it is therefore usually only population changes (for example, a decline in the birth rate) which give real scope for the contraction of services. Proposals to reduce a service will be opposed by those who wish to improve it and claim that they must retain their threatened resources to enable them to do so. The NHS employs a large number of workers, many of them specialised. More than marginal changes in the priority given to different services would mean moving, training and retraining staff. Resistance to such change is usually intense.
6.13 A further difficulty about implementing nationally determined priorities lies in allowing for specific local factors. Local pressures may conflict with national priorities, and there may be strong ties of loyalty to particular services or institutions. Diversion of funds from one district or area to another required by national priorities may be sternly resisted by those responsible for managing the health service locally, as well as by staff and the local community.
The planning system
6.14 The main mechanism for implementing the government’s priorities in the NHS is the planning system. Ministers and health authorities need a framework within which choices can be made in the full knowledge of the possibilities available and any wider consequences of them. The planning process is designed to provide this framework.
6.15 In England a systematic planning process was introduced in the DHSS in 1974, and the NHS planning system and a system of social services planning were initiated in 1976. The planning process in the field is set in motion each year with the issue of guidance from the Secretary of State on policies and priorities and on the resource assumptions within which planning should proceed. The initial guidance was published as a consultative document, and the whole process is seen as consultative rather than directive. The health authorities’ responses are contained in the documents submitted to the DHSS, and these are taken into account by the Secretary of State in his regular reviews of planning guidance. The planning system also enables the consistency of health authorities’ plans with national policies to be checked, and the development of services to be assessed. Planning guidance is flexible in two senses; it is subject to review over time, and it is considered by field authorities in the light of local circumstances. Substantial divergence from the national pattern may be justified in particular circumstances, and indeed may result in a better use of available resources. But the reasons for it may merit exploration, and that may lead to review of the national guidance itself.
6.16 In conjunction with the planning system the DHSS has developed a programme budget approach as a means of costing policies for services development across the board. Expenditure can be allocated to broad patient and client groups, and can show the trends in spending on the groups identified. Health and personal social services expenditure in England by programme for the period 1975/76 to 1977/78 is shown in Table El in Appendix E (comparable figures are not available for earlier years). Too much weight should not be given to these figures, but they suggest that over the last three years the pattern of expenditure by health authorities has been broadly consistent with the current DHSS priorities.
6.17 We agree with the Expenditure Committee that:
“the expenditure planning and priority-setting of DHSS should be synchronised so as to enable Parliament to examine the relationship between the two ”
but even after listening to careful explanation by representatives of the DHSS about the way in which the needs of particular priority groups are taken into account in the allocation of resources to health authorities, we remain mystified. We are bold enough to think that this is because there is some cloudiness in the Department’s thinking about these matters, which are as important as anything in the Department’s care.
6.18 Broadly comparable planning arrangements tailored to local needs have been developed in Wales. The health authorities prepare annually operational plans covering a four year period and strategic plans looking ten years ahead, which are then reviewed by the Welsh Office and taken into account in planning guidance and resource allocation. In addition the Welsh Office allocates provision for all-Wales services and retains responsibility for the long-term all-Wales capital programme. In Northern Ireland a similar planning system has been developed for both health and personal social services. The health and social services boards prepare annually detailed comprehensive plans for the development of services covering the following five years, with general proposals for a further five years. These plans are then considered by the Department of Health and Social Services (Northern Ireland), and an overall plan, which is reviewed and up-dated annually is prepared.
6.19 Arrangements for planning differ in Scotland where at reorganisation the Scottish Health Services Planning Council was established with representatives of the health boards, the universities and the Scottish Home and Health In addition there are national consultative committees for the main health professions which tender advice to the Secretary of State through the Planning Council. The Council has played a major part in the development of priorities for the health service in Scotland and has set up a number of multi-disciplinary programme planning groups which have reported on services for particular patient and client groups. The Chairman of the Council, Professor EM McGirr, told us that:
“Health planning in Scotland is built into the central decision-making process to a significant extent. On the other hand, the way the planning council and the national consultative committees have been constituted also ensures that central planning is not over centralised.”
Earmarked allocations
6.20 A more direct method of implementing national priorities, is to earmark part of the funds allocated to authorities for use in particular services. In the period 1971-76 additional capital allocations totalling more than £44 million were made to health authorities in England to be spent on mental handicap, mental illness and geriatric services, though with little noticeable effect on the overall proportion of capital expenditure devoted to services for those three groups. Currently health authorities in England are receiving funds specifically allocated for the development of regional secure units, but these funds have sometimes been diverted to other purposes. While earmarking within the general allocation can influence the pattern of expenditure it evidently cannot ensure that funds are used for the purposes intended. A variation is to make additional funds available outside the normal allocation for use on specific projects, such as capital funds for the development of health These funds are separately administered and cannot be diverted to other uses, but may not be fully taken up. In the same way, capital and revenue funds in England and Wales allocated for projects undertaken in collaboration with local authorities, although a part of health authorities’ normal allocations, cannot be used for other purposes.
6.21 A disadvantage of earmarked allocations is that they reduce the discretion of health authorities to tailor their policies and priorities to local needs within the framework of national policy guidelines (the philosophy of the planning system), and undermine the influence of the individual health On the other hand it may be that a substantial shift of resources to the “Cinderella” services cannot otherwise be achieved.
6.22 Priorities are generally expressed in a way which makes their implementation difficult to measure. Over time, progress can be checked through centrally collected statistics: activity and staffing statistics and financial returns. The development of the planning systems should mean that the health departments are better able to monitor the implementation of priorities, but it is too early yet to know whether these hopes are being realised and expenditure is leading to the achievement of desired outcomes.
Information
6.23 Good information is of prime importance for planning purposes. In Chapter 21 we refer to some of the defects in existing arrangements for collecting statistical and other information in the NHS. We are therefore pleased to note that the DHSS has recently undertaken a study of information requirements of the health services, and a consultative document was circulated in the NHS in February this year. The document proposes a joint NHS/ DHSS Steering Group “to provide a permanent forum for considering information matters”. We support this approach, and suggest that other government departments and local authorities, who both contribute to, and make use of, information relevant to the NHS, should be involved.
Current priorities
6.24 Current NHS priorities are services for the elderly, the mentally ill, the mentally handicapped and children. Community services are also being developed, along with services for some smaller groups of patients whose needs have in the past been neglected. There is considerable overlap between the four main patient groups currently being given priority. The major problem of mental illness is now the dementias of old people, and it is therefore impossible to plan services for the old and the mentally ill separately. The mentally handicapped may also be mentally ill and this is one of the commoner reasons for their continued stay in hospital. Children may be mentally handicapped or become mentally ill. “Programme planning” of services has therefore not only to be comprehensive for each patient group but has also commonly to be “joint” in that it involves more than one provider of services and must take into account the needs which more than one of these groups have in common.
6.25 Children apart, the priority groups have other features in common. The resources devoted to their care by the health authorities have been less than those allocated to other patient groups, while the services for them have had persistent recruiting difficulties and have been staffed by a high proportion of men and women from overseas. In recent years these men and women, trained and untrained, have given invaluable service in psychiatric and geriatric hospitals; but the quality of the care which they can provide is limited by deficiencies in communication, because they come from cultures with different assumptions and conventions and have often an imperfect command of English. Where understanding, diagnosis and treatment all depend upon ease of communication, and where abnormalities of attitude and behaviour of a subtle kind may be of great significance, staff from overseas may be at a serious disadvantage and patients may suffer in consequence.
Community care
6.26 For all the priority groups the present policy of the health departments is that wherever possible, care should be provided in the community rather than in institutions. First, it is said that care in the community is generally preferred by most patients, providing they can be assured that their needs are being adequately met, and that they should be admitted to hospital only when they require those forms of treatment and care which cannot effectively be provided in their homes. Second, it is argued that care in the community will relieve pressure on the hospital services and may be cheaper. There are, however, a number of difficulties about comparing the costs of treating or caring for patients in hospitals and at home. The degree of dependency of patients may vary, the quality of treatment and care may be different and is difficult to measure, the outcome or effectiveness of the treatment is hard to assess, and treatment at home may impose heavy burdens on relatives and More research is required into the relative costs and effectiveness of hospital and community provision for conditions where there is an option about the place of treatment.
6.27 Community care is provided primarily by families or neighbours, with the support of the health and personal social services. Its expansion requires additional facilities, such as health centres, day hospitals and day centres, which involve capital expenditure. The main requirement, however, is additional staff: GPs, district nurses, health visitors, home helps, chiropodists, midwives and others. Expenditure on community health services is a relatively small proportion of total NHS expenditure, but adjustment of the pattern of care will inevitably be slow unless additional resources are made available to both NHS and local authority services. Some of the other difficulties have already been mentioned: for example, it may take time to recruit or retrain staff with the necessary professional skills. Community care is especially dependent on co-operation between health and personal social services, but (except in Northern Ireland) two separate authorities must be prepared to work together and agree to give priority to this aspect of their functions, rather than to other pressing local needs, if the necessary change in emphasis is to be Other services have an important influence on community care; for example in Great Britain nearly 30% of local authorities’ new house building is devoted to housing designed for old people and a number of new cash benefits have been introduced in recent years to ease the burden on relatives or others caring for elderly or disabled people at home.
6.28 Teamwork is of central importance in community care. A patient may need the support and services of several different workers, who may be employed by health authorities or local authorities, or who may be independent contractors. Effective teamwork is much easier where there is regular contact between all those involved. The increased number of health centres has done much to facilitate effective teamwork, and this is discussed more fully in Chapter 7.
6.29 The extent to which there has been a switch in emphasis from hospital treatment to care in the community in recent years is difficult to measure. One indication would be the number of in-patient treatments in relation to the number of out-patient or day patient treatments or day hospital attendances. This is set out for three patient and client groups in Table 6.1, which suggests that for the elderly, the mentally ill and the mentally handicapped there has been some development of care in the community. The hospital population for these groups over the same period is shown in Table 6.2. In spite of an increasingly elderly population, the number of patients in geriatric departments has remained constant and the number of patients in mental illness and mental handicap hospitals and units has declined. However, in the case of the elderly these figures could reflect a failure to provide adequate in-patient accommodation as much as a deliberate attempt to provide services in the community.
Table 6.1 Patients Receiving In-Patient, Out-Patient or Day Patient Treatment: Great Britain 1970-1976
Thousands
| 1970 | 1973 | 1976 | % change over period | |
| Geriatrics1 | ||||
| discharges and deaths | 201 | 220 | 259 | 28.9 |
| out-patient and day case attendances | 149 | 189 | 244 | 63.8 |
| day hospital attendances2 | 580 | 838 | 1,172 | 102.1 |
| Mental Illness | ||||
| discharges and deaths | 212 | 217 | 219 | 3.3 |
| out-patient and day case attendances | 1,748 | 1,880 | 1,877 | 7.4 |
| Mental Handicap discharges and deaths | 15 | 18 | 19 | 26.7 |
| out-patient and day case attendances | 16 | 26 | 28 | 75.0 |
Source: compiled from health departments’ statistics.
Notes: Includes younger disabled. 2 England only.
TABLE 6.2
Hospital Population; Daily Occupied Beds: Great Britain 1970-1976
Thousands
| 1970 | 1973 | 1976 | % change over period | |
| Geriatrics ‘ | 65 | 65 | 65 | 0 |
| Mental Illness | 131 | 117 | 105 | -19.8 |
| Mental Handicap | 64 | 61 | 58 | -9.4 |
Source: compiled from health departments’ statistics. Note: ‘ Includes younger disabled.
6.30 A better measure of the extent to which there has been a switch from hospital to community care might be the number of staff employed in the community in relation to the numbers of staff employed in hospital. The figures in Table 6.3 describe a complex situation but do not indicate a greater increase of staff in the community.
TABLE 6.3
Staff Employed in Community Care and in Hospitals: Great Britain 1974-77
Whole-time equivalents
| 1974 | 1977 | % Change over period | |
| COMMUNITY CARE STAFF | |||
| District Nurses | 12,428 | 14,929 | 20.1 |
| Health Visitors | 9,861 | 10,248 | 3.9 |
| Social Workers | 24,414 | 28,3 17 | 16.0 |
| Home Helps | 53,860 | 56,687 | 5.2 |
| General Medical Practitioners (numbers) | 25,844 | 26,810 | 3.7 |
| HOSPITAL STAFF | |||
| Hospital nursing and midwifery staff | 333,592 | 369,983 | 10.9 |
| Hospital medical staff | 31,486 | 36,293 | 15.2 |
Sources/compiled from health departments’ statistics.
6.31 We have not been able to reach a firm judgement about whether the present balance between community and hospital care is correct. The pattern of health services varies in different parts of the country, and probably both reflects and conditions local needs and preferences. We think it right that the emphasis should be on the development of community services. Although in some places it may be possible to transfer resources from the acute hospital services, in general those services are already severely constrained, and often in need of improvement. It follows therefore that the development of community care requires additional resources and at a time when the resources available to the NHS and to local authorities are growing slowly, progress will necessarily be restricted. We say more about the relationship between hospital and community care in Chapter 10.
Services for the elderly
6.32 Meeting the health needs of the elderly is one of the major problems facing the NHS. The higher age groups are increasing both in absolute numbers and as a proportion of the total population, and Table 6.4 shows that this is particularly marked for those aged 75 and over and 85 and over. At the same time the number of women in the 45-60 age group who provide the main source of support for old people in the community, will fall in the next decade. Expenditure per head on health services is almost six times as much for people aged 75 and over as for people aged 16 to 64. They also make heavy demands on the support provided by the local authorities, particularly in personal social services and housing. The health departments are well aware of the problems created by the increasing number of old people. The DHSS and the Welsh Office published “A Happier Old Age: a discussion on elderly people in our society” in 1978, and this is to be followed by a White Paper on services for the elderly this year. The needs of the elderly in Scotland are being considered by a Programme Planning Group set up jointly by the Scottish Health Services Planning Council and the Scottish Advisory Council on Social Work. A review of the needs of the elderly is also being carried out in Northern Ireland.
TABLE 6.4 Projected Elderly Population: UK 1976-1996
| Persons aged 75 and over | Persons aged 85 and over | |||
| Numbers (thousands) | % of total population | Numbers (thousands) | % of total population | |
| 1976 | 2,842 | 5.07 | 520 | 0.93 |
| 1986 | 3,407 | 5.96 | 612 | 1.07 |
| 1996 | 3,498 | 5.91 | 740 | 1.25 |
Source: Office of Population Censuses and Surveys, Population Projections 1974-2014, London, HMSO, 1976.
6.33 Services for the elderly demonstrate very clearly the requirements for community care already discussed. Everything possible should be done to assist old people to remain independent, healthy and in their own homes. It is important to detect stress and practical problems, and to ward off breakdown, for example by regular visiting of those who are identified through GP case registers as being at risk, by providing physical aids or adapted or sheltered housing, and by assistance from home helps, chiropodists, or meals on wheels. Planned short-term admissions to residential care play an increasing part in helping the elderly remain in their own homes or with relatives. The supporting role of relatives is of great importance and their needs for relief from time to time must be met. Voluntary bodies and volunteers can often help in numerous understanding ways. Where there is illness the full resources of the primary care team have often to be deployed, and a heavy load of work and responsibility falls on the district nurses and the home help services. Day centres are helpful, and day hospitals have been widely developed: their place in a comprehensive service urgently requires critical evaluation and this is being studied by the DHSS. When independence at home is no longer possible, care in a nursing home or local authority residential home may be appropriate.
6.34 Illness in old age commonly has both physical and mental aspects. A deterioration in an old person’s faculties may or may not be accompanied by disturbances of behaviour, and may or may not be due to or worsened by physical illness. Detailed assessment is often necessary and the skill of geriatricians, psychiatrists, nurses and social workers may be jointly called We recommend that all professions concerned with the care of the elderly should receive more training in understanding their needs.
6.35 Many elderly patients admitted to district general hospitals do not need the technology which that type of hospital can provide. They frequently remain in hospital long after any investigations or active treatment have been completed because they are not fit to go home and there is nowhere else for them to go. Residential homes cannot care for those who are physically very dependent and need nursing care, or whose behaviour is more than mildly disturbed.
6.36 In any plans for the care of infirm old people in the NHS nurses must play the most important part: they are the only category of caring staff essential when active treatment is no longer possible. Recruiting and retaining these nurses will present an increasing problem. Many nurses, like others in the health professions, do not want to look after mentally disturbed old people. Commenting on the DHSS Consultative Document “Priorities for Health and Personal Social Services in England” the Royal College of Nursing noted that:
“those engaged in this work tend to be regarded as having opted for a less demanding branch of nursing”
by their nursing colleagues. They may be so regarded but it is grossly unfair: it is one of the most demanding branches of nursing, calling for personal qualities and skills of a high order, and it should be so rewarded. The Royal College of Nursing also noted that;
“the Joint Board of Clinical Nursing Studies has produced some excellent courses in this speciality, but the take-up has been very disappointing.”
6.37 Since the burden of care will fall predominantly on nursing staffs, they should have a major influence in determining the conditions under which they will work. We were impressed by some of the arrangements we saw for the care of the elderly during our overseas visits, and particularly by the nursing homes in Denmark. There, old people needing long term care were normally accommodated in single rooms for which they were expected to provide their own furniture, and were encouraged to maintain a social life and be as active physically as they were able. Unfortunately large numbers of old people are too frail to be able to achieve even such a moderate degree of independence. We recommend that further experiments in different ways of meeting the needs of elderly and other patients requiring long-term care should be undertaken urgently.
6.38 Geriatricians do not deal comprehensively with the health and sickness problems of this age group, even if one excludes surgical cases. Where mental illness or dementia is the dominant feature of the old person’s state, as it often is, the geriatrician may take the view that a psychiatrist should look after him. The geriatrician is basically a physician, and most physicians working in hospitals now have to care for a great many old people. In view of the considerable difficulties of recruitment into the specialty, and the fact that the majority of those recently appointed to consultant posts are doctors from overseas, doubts have been expressed whether geriatric medicine can be a viable specialty. Whether or not it should be considered a specialty, it is certain that not all elderly disabled people can be cared for by specialist geriatricians: there are not, and will not, be enough of them. The care of the old is inescapably part of the mainstream of medicine, the daily responsibility now of physicians, psychiatrists and surgeons, and it must remain so.
6.39 We consider that there is a place for specialisation in the care and treatment of the illnesses of old age, but that this should usually be a part-time commitment, the doctor being a physician or psychiatrist with a “special interest” in geriatrics. This is an approach which has the support both of the Royal College of Physicians of London and the Royal College of Psychiatrists. Such a specialist interest can be fostered in postgraduate training programmes and built into contracts of service. It is a more flexible, and for many a more attractive category than whole-time specialisation. There has, we think, been too much emphasis on the latter by some of the leaders in this field.
6.40 Nevertheless, some doctors will continue to wish to give all their attention and energies to this field of work and this should also be welcomed. Some pioneering physicians and psychiatrists have devoted themselves to geriatrics and have contributed outstandingly to knowledge and to improved standards of investigation and care. These are the people who lead and develop They may also wish to pursue this field of work in an academic setting: important advances have been made in university departments of geriatric medicine. There is a paucity of such research, but the limiting factor is the lack of talented research workers rather than the amount of money potentially available.
Services for the mentally ill
6.41 In the detection and treatment of psychiatric illness the largest and most important role is played by general practitioners. A survey of general practices in London showed that 14% of the patients had “consulted at least once during the survey year for a condition diagnosed as largely or entirely psychiatric”. Similar findings have been reported in other surveys. Most patients with these conditions are treated by GPs themselves: fewer than five per cent are referred to psychiatrists. Yet most GPs consider themselves inadequately trained and equipped to deal with these problems. It is therefore of prime importance that the competence of the primary care team should be strengthened in this respect. It is an aspect of care with which the public already show some dissatisfaction by their complaints of GPs not having time to listen to them. It is impossible to do justice to psychiatric problems within the present average consultation time of six minutes. GP trainees can now spend part of their three years’ vocational training in gaining psychiatric experience. It is to be hoped that many will do so, but it will be necessary also to review the content of continuing education in general practice, the place of psychologists in the primary care team, and the possible training of other members of the team in techniques of counselling.
6.42 In many places the psychiatric services have long embraced hospital and community elements, and in the community both the NHS and the social services departments of local authorities make major contributions. The NHS provides mental hospitals and the psychiatric units in district general hospitals (DGHs), day hospitals, out-patient clinics, supervised hostels and community psychiatric nursing services; and the local authority provides hostels, group homes, supervised lodgings, sheltered workshops and social casework of many
6.43 Psychiatry is a shortage specialty. Though there has been a considerable expansion of the specialty in the last decade its staffing levels do not match the demands made upon it. Recruitment has recently fallen off: there are consultant posts unfilled and recruitment to the training grades has been deficient in both quantity and quality. Until the quality of recruitment improves it would be unwise to promote expansion of the specialty.
6.44 There are problems with the provision of hospital services for the mentally ill. The development of psychiatric units in DGHs in itself desirable, has had the effect of leaving to the large specialist mental hospitals the incurable, the behaviourally disturbed, the old and demented. The policy of running down these institutions has undermined the morale of their staff. Nevertheless they can provide facilities and a therapeutic environment of a kind which cannot be provided by a psychiatric unit in a DGH. We discuss their problems in Chapter 10.
Services for the mentally handicapped
6.45 It is an accident of history that the NHS has such a large responsibility for the mentally handicapped. Medical and nursing staffs have had to look after those whom society and other disciplines have rejected. Recently the situation has changed; the education of the mentally handicapped has become the responsibility of the education departments of local authorities, and their social services departments have been more active in providing training centres, hostels and residential homes. But the community provision is still far less than it should be, except in the case of children where a higher proportion of the hospital population has recently been discharged to community care. Most mentally handicapped people need no more medical attention than the average person. Some require intensive attention from psychiatric, medical and other specialties, as well as skilled nursing, and in-patient treatment and care in hospital may be imperative.
6.46 The general strategy for the development of these services was set out in the White Paper “Better Services for the Mentally Handicapped” in 1971, and has general assent. A National Development Group for the Mentally Handicapped and a Development Team have been instituted in England and Wales. Prevention of mental handicap is of prime importance, research in this has been adequately supported and progress has recently been made.
6.47 Many people working in these services would like to see them comprehensive, specialist and distinct. Others consider that their isolation has been a major problem, and overcoming this professional, social and geographical isolation appears to be the key to their improvement. Those who hold the first view get little or no support from the facts of the present situation. Staffing presents a major problem and looks like getting worse. Recruitment of doctors is poor both in quantity and quality. Many trained nurses are approaching retirement age, there is a high proportion of untrained staff and high staff turnover. About 25 per cent of the teachers are reported to be without professional qualifications, and still more are without specialist training in teaching the severely mentally handicapped. There is a serious shortage of clinical psychologists, who have an essential contribution to make in diagnosis and treatment. The fact that several enquiries have had to be set up in England and Wales and have reported adversely on the conditions they have found in hospitals for the mentally handicapped shows that, whether or not it is carrying too extensive a responsibility, the NHS is, in certain places at least, failing badly to fulfil its obligations.
6.48 As in the case of the medical specialty of geriatrics, we consider that there is a place for the full-time wholly committed specialist but much greater scope for appointments shared with other specialties. Specialists in child and adult psychiatry and paediatrics have a most important part to play in the care of the mentally handicapped, particularly in supporting those nurses, residential staff and families who have the responsibility for full time care. Every effort should be made to encourage this by funding joint appointments. This development has been resisted by some of the longer established, whole-time specialists in mental handicap, but we consider this short-sighted and ultimately self-defeating. Similarly, the barriers between mental handicap and the other branches of nursing should be taken down. Many who would not be prepared to make this their life’s work might be prepared to work for a time, or work part-time, in this most challenging field.
6.49 The Jay Committee reported recently on mental handicap nursing and The report makes important recommendations on the training of residential care staff and the management of residential units, whether in hospital or local authority accommodation. Consultation on the report has only just begun, and we have not had time to consider its recommendations in detail.
Services for children
6.50 A range of services for children is provided under the NHS – general medical services and complementary primary health care including the health visiting service, community health services and child health clinics, school health services, and hospital paediatric services. In 1974 the reorganisation of the NHS brought all these services together for the first time under the new health authorities. At the same time “the provision made for health services for children up to and through school life [and] the use made of these services by children and their parents” were being considered by the Court Committee which reported in 1976. An implication of the reorganisation of the NHS, which is elaborated in the Court Report, is that there should be much closer co-operation and integration of the various health services for children. While the government have not accepted some of the Committee’s detailed recommendations which were aimed at creating an integrated child health service, we urge that they continue to bear that objective in mind.
6.51 One problem in the field of child health services to which the Court Committee drew particular attention was the continuing comparatively high rate of perinatal mortality in the UK. The figures in some geographical areas and the higher rates in social classes IV and V are disturbing. Against this background the health departments have advocated the concentration of maternity facilities in a smaller number of properly equipped and staffed maternity units, which will normally be situated in district general hospitals. They have urged that more special care “baby cots” should be provided where there are shortages. It is also necessary to improve the health and related services (including genetic counselling) available to women during pregnancy, and their take-up of these services.
6.52 The Court Committee identified health surveillance as one of the main functions of the child health services. By this they meant evaluation of the child’s state of health and pattern of growth, monitoring development, providing advice and support for parents and arranging further examination or treatment where necessary, providing an effective immunisation programme and health education. At present these functions are carried out at different times and in different places by different people. Some general medical practitioners hold regular child development clinics for their patients and health visitors undertake routine child development surveillance of the normal population. Often there is little liaison with the community child health services. It is important that co-ordinated programmes of child health surveillance should be developed, and especially that efforts should be made to ensure that all children are covered.
6.53 The Court Committee examined the school health service and identified a number of problems:
- restricted ability to meet the needs of school children caused by the nature, organisation and concentration on regular medical examinations;
- failure to meet the needs of adolescents directly by advising parents and teachers rather than the teenagers themselves;
- failure to give adequate attention to health education;
- the isolation of school health staff from relevant specialist services and problems of effective communications between GPs and school doctors.
The Committee thought that every school should have a nominated doctor and nurse with appropriate training and sufficient time to get to know their schools well. They would be responsible for all aspects of health within the school and for liaising with other NHS services. The Committee emphasised the importance of the school nurse as “the representative of health in the everyday life of the school” and recommended the appointment of full-time nurses to large secondary schools. The government rejected the proposal for specialist professional grades in school health, but accepted the principle of a better and more integrated service, and more research and experimentation with providing school health services.
6.54 We agree with the general approach of the Court Committee’s recommendations though not with their proposals for new categories of staff. Routine school health care seems to be a logical extension of the responsibilities of the primary health care teams; and it would be valuable if post-graduate educational programmes could enable some GPs to obtain the training needed for them to develop a special interest in paediatrics. To focus attention on, and bring help to, particularly vulnerable families and children at risk will call for close collaboration between general practitioners, health visitors and social workers.
Some other services
6.55 In Chapter 10 we comment on the rehabilitation services. We found it convenient to consider briefly at this point service for the deaf, and for the blind and partially sighted.
Services for the deaf
6.56 There are perhaps two and one half million people in the UK with a degree of hearing loss that constitutes a social handicap. The DHSS estimate that about 120,000 children under the age of 16 may be experiencing difficulty in hearing at any one time, including those with temporary conditions. Despite these large figures we received very little evidence about services for the deaf.
6.57 Services for adult patients with hearing problems are based on hospital ear, nose and throat departments. Children may be treated in hospital or in clinics. Some with hearing impairments require surgery: those who do not are often helped by the provision of a hearing aid, normally supplied free of The early detection of hearing impairment in young children is important, because if it is not detected it can cause serious damage to the child’s intellectual, emotional and social development. Health authorities aim to screen all children for hearing impairment in the first year of life and again shortly before or after entering school, as part of the routine child development surveillance undertaken by health visitors.
6.58 We were pleased to learn of a number of promising developments in services for the deaf. The medical Royal Colleges agreed in 1975 to the creation of a new specialty of audiological medicine concerned with the medical and rehabilitative aspects of deafness. Increasing numbers of scientific and technical supporting staff are becoming available. There have also been improvements in hearing aids, and hearing aids centres are being established by health authorities. The needs of the elderly deaf are often seriously neglected and the NHS and local authorities should collaborate to ensure an improvement in this position.
Services for the blind and partially sighted
6.59 The great majority of eye problems are dealt with by the general ophthalmic services which we discuss in Chapter 8. The problems reported in our evidence were mainly to do with obtaining spectacles.
6.60 In general, services for the blind and partially sighted are well developed in the United Kingdom. A particular point on which we would like to comment here is the availability of low vision aids which enable blind and partially sighted people to retain their mobility and independence. These aids include simple magnifiers; individual multi-lensed optical devices to assist close work; distance telescopes to help with the identification of bus numbers, road signs, etc; and even closed circuit television systems which reproduce at a high degree of magnification book pages, etc. Low vision clinics exist in some places, but a survey carried out in 1974 concluded that half the registered blind and partially sighted population who could benefit from low vision aids had not had an opportunity to try them. Extension of the service could reduce the need for training in the reading and writing techniques of the blind.
Conclusions and recommendations
6.61 The present national priorities set for the NHS are services for the elderly, the mentally ill and mentally handicapped, and children. The emphasis is on community care. These priorities are not the result of objective analysis but of subjective judgment. Our own view is that they are broadly correct at the present time, but they are certainly not the only possible choices. It is important to recognise that national priorities emerge from a variety of conflicting views and pressures expressed in Parliament, by the health professions and various patient or client pressure groups amongst others. So far as possible discussion which leads to the establishment of priorities should be conducted in public and illuminated by fact.
6.62 Implementing priorities gives rise to other problems. There are considerable practical problems to be overcome in shifting resources from one patient or client group to another, or in favouring one part of the NHS against others, particularly when funds are short. It remains to be seen how far the NHS planning system introduced after reorganisation will turn out to be an effective mechanism for this purpose. National priorities can in any case only be uniformly applied to a limited extent. Some of the difficulties may be seen in the efforts to promote community care, and unless additional resources are made available progress will be slow.
6.63 Services for the elderly will make increasing demands on health and local authorities for the rest of this century. We are concerned that without greater shifts in resources than are yet evident neither health nor local authority services will be able to cope with the immense burden these demands will impose. Inevitably the community as a whole will have to share the responsibility and cost of caring for the elderly at home with appropriate support from the health and personal social services. The health departments are already tackling the implications and integrated planning of services at all levels is essential. In the NHS the burden of caring for infirm old people will fall mainly on nurses, and efforts must be made to encourage them in undertaking this work.
6.64 Hospital provision for the mentally ill and mentally handicapped is discussed in Chapter 10, but most problems with a psychiatric aspect are first identified by GPs. It is clear that many GPs would benefit from more training in this part of their work. We doubt whether medical care for the elderly and mentally handicapped is best organised on the basis of separate specialties. Other doctors should be involved in the care of these patients, and we see the development of special interests by doctors in related specialties as being a promising way of achieving this.
6.65 The Court Committee has recently looked in depth at services for children and we have not considered it necessary to go over that ground again in detail, but, like others, we have doubts about the wisdom of introducing new specialist staff into this field. Finally, we welcome recent developments in services for the deaf, and would like to see improved services for the partially
6.66 We recommend that:
- the health departments should make public more of the professional advice on which policies and priorities are based (paragraph 6.7);
- all professions concerned with the care of the elderly should receive more training in understanding their needs (paragraph 6.34);
- further experiments in different ways of meeting the needs of elderly and other patients requiring long-term care should be undertaken urgently (paragraph 6.37).